Anatomic relations of the Marshall vein: importance for catheterization of the coronary sinus in ablation procedures.

AIMS: Our objective was to study the anatomic relations of the human left atrial oblique vein (Marshall vein), particularly of its ostium opening into the coronary sinus, in order to guide ablation procedures related to that vein. METHODS AND RESULTS: The study was carried out in 23 heart-specimens (mean weight 446 +/- 204 g) of individuals whose mean ages were 43 +/- 21 years, 20 males. The coronary sinus was opened longitudinally, exposing the ostium of the tributary veins; the Vieussens valve was looked for, as well as its relationship to the left atrial oblique vein. The diameters of the left atrial oblique vein and the coronary sinus ostia were measured and the distance between them was determined. The left atrial oblique vein could be identified in 20 (87%) of the hearts, while the Vieussens valve was present in 17 (74%) of the specimens (in 16 of which the left atrial oblique vein was identified). In such condition, the vein was adjacent to the Vieussens valve and proximally positioned relative to the coronary sinus ostium in most of them (14/16 cases). The mean diameters of the left atrial oblique vein and of the coronary sinus ostia were, respectively, 1.23 +/- 0.38 and 8.22 +/- 1.88 mm. The mean distance between both ostia was 30.9 +/- 10.2 mm. CONCLUSION: When present, the left atrial oblique vein can be easily recognized, adjacent to the Vieussens valve. The mean distance between the coronary sinus opening and left atrial oblique vein ostium was around 30 mm, independently of the heart weight and the presence of cardiomegaly.     

Baroreflex Sensitivity and its Association with Arrhythmic Events in Chagas Disease

Background

Sudden death is the leading cause of death in Chagas disease (CD), even in patients with preserved ejection fraction (EF), suggesting that destabilizing factors of the arrhythmogenic substrate (autonomic modulation) contribute to its occurrence.

Objective

To determine baroreflex sensitivity (BRS) in patients with undetermined CD (GI), arrhythmogenic CD with nonsustained ventricular tachycardia (NSVT) (GII) and CD with spontaneous sustained ventricular tachycardia (STV) (GIII), to evaluate its association with the occurrence and complexity of arrhythmias.

Method

Forty-two patients with CD underwent ECG and continuous and noninvasive BP monitoring (TASK force monitor). The following were determined: BRS (phenylephrine method); heart rate variability (HRV) on 24-h Holter; and EF (echocardiogram).

Results

GIII had lower BRS (6.09 ms/mm Hg) as compared to GII (11.84) and GI (15.23). The difference was significant between GI and GIII (p = 0.01). Correlating BRS with the density of ventricular extrasystoles (VE), low VE density (<10/h) was associated with preserved BRS. Only 59% of the patients with high VE density (> 10/h) had preserved BRS (p = 0.003). Patients with depressed BRS had higher VE density (p = 0.01), regardless of the EF. The BRS was the only variable related to the occurrence of SVT (p = 0.028).

Conclusion

The BRS is preserved in undetermined CD. The BRS impairment increases as disease progresses, being more severe in patients with more complex ventricular arrhythmias. The degree of autonomic dysfunction did not correlate with EF, but with the density and complexity of ventricular arrhythmias.     

Applicability of the PAINESD risk score for 30-day mortality prediction post ventricular tachycardia catheter ablation in Chagas disease

Background

Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) is standard of care. However, it is underutilized. In July 2012, our institution began providing cell phone adapters (CPAs) to patients free of charge following CIED implantation to improve remote transmission (RT) adherence.

Methods

Patients in our institution’s RM database from January 1, 2010, thru June 30, 2015, were retrospectively reviewed. There were 2157 eligible patients. Remote transmission proportion (RTP) and time to transmission (TT) were compared pre- and post-implementation of free CPA. Chi-squared analysis and Kruskal-Wallis tests were performed to compare RTP and TT.

Results

There was a significant increase in RTP (134 [18.4%] vs 99 [54.7%]; p?<?0.001) and decrease in median TT in days (189[110–279] vs 58 [10–149]; p?<?0.001) after CPAs were provided to patients. Caucasian patients were more likely than African Americans and Hispanics to use RM prior to CPAs (p?=?0.04). After the implementation of CPAs, there was a significant increase in RTP for all racial groups (<?0.001) with no difference in RTP among racial groups (p?=?0.18). The RTP for urban residents was significantly greater than non-urban residents with CPAs (p?=?0.008). Patients greater than 70 years of age were significantly less likely to participate in RT before and after CPAs were provided (p?=?0.03, p?=?0.01, respectively).

Conclusions

CPAs significantly improve RTP and reduce median TT for all patients regardless of race, geographic residence, and age (>?70 years old to lesser extent). Broad institution of CPAs following ICD implantation could potentially reduce disparity in RTP and deserves more study.

     

Radiofrequency ablation of sustained ventricular tachycardia related to the mitral isthmus in Chagas' disease

This case report describes the electrophysiological findings of a 62-year-old patient with chronic Chagas' disease and two distinct morphologies of sustained ventricular tachycardia that involved a mitral isthmus. Multiple RF applications were necessary to obtain a bidirectional conduction block in the mitral isthmus that was related to the interruption of both tachycardias. After the procedure, the patient presented massive cerebral infarction that progressed to coma and death. Autopsy showed acute and old lesions at the mitral isthmus and recent mitral annulus thrombosis.